Provider Demographics
NPI:1326783689
Name:EVIDENCE BASED TREATMENT CENTERS OF SALT LAKE CITY, PLLC
Entity Type:Organization
Organization Name:EVIDENCE BASED TREATMENT CENTERS OF SALT LAKE CITY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:425-361-9272
Mailing Address - Street 1:1200 5TH AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-3136
Mailing Address - Country:US
Mailing Address - Phone:206-374-0101
Mailing Address - Fax:206-374-0108
Practice Address - Street 1:2225 E MURRAY HOLLADAY RD STE 116
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5382
Practice Address - Country:US
Practice Address - Phone:206-374-0109
Practice Address - Fax:206-374-0108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVIDENCE BASED TREATMENT CENTERS OF SEATTLE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty